Miami-Dade Blue Health Insurance
Plan Concerns Questions Answered
Here are some of the most typical
questions we answer about the new Miami Dade Blue
health insurance plan from Blue Cross Blue Shield of
Florida for Individual and Families. Most people
in fact have the same concerns, and we will do our
best to address all of them and keep you updated by
posting as many questions and answers as we can.
If you have any
questions about the Miami Dade Blue Cross plan please
email them to us.
I think I understand it (the Miami
Dade Blue Cross Plan) pretty well,
but one question…let’s say that someone goes to the ER
and has surgery…are they charged two deductibles (1
for surgery, and 1 for ER admission)? Secondly,
with Miami Dade Blue maternity, is there a time frame that we need to have it
before she gets pregnant or a waiting period? We
are still looking a
year or two down the road, but I was just wondering.
She is wanting to get her yearly checkup and possibly
a mammogram. Am I reading this right that the
mammogram is free on Miami Dade Blue Cross?
So if someone goes to the ER and has surgery then no,
they would not have two deductibles apply, only the
$250 calendar year would apply. However, if
someone were to go to the ER and NOT have surgery or
get admitted then yes, they would have to pay a PER
VISIT DEDUCTIBLE for the ER visit in addition to their
calendar year deductible and 10% coinsurance.
The calendar year deductible and 10% coinsurance would
go towards your out of pocket maximum amount of $2500;
the $500 PVD (per visit deductible) to ER if not
admitted or for non-surgical services would not go
towards your maximum out of pocket amount of $2500.
You would just need to have the maternity benefit
effective 30 days prior to conception - that's the
waiting period; actually really good - it's the same
as in all their other PPO plans.
Yes the annual mammogram is free of charge $0 as long
as she stays in network. And if she wanted to do
her yearly pap smear and physical exam then I'm sure
you already know this, but just wanted to mention it
just in case; then BCBSF would pay $50 towards or the
allowed amount (whichever was less) and your wife
would pay the difference up to that allowed
(negotiated rate) for that service or any other for
that matter performed at a doctor's office visit.
Please find attached rate sheet for the Miami Dade
Blue plan in which will indicate that the total
monthly premium for your wife assuming that she is a
non-smoker would be $98.00. I've also included the
rate sheet for this plan with maternity benefits just
in case she wanted to add that optional benefit now or
later (30 days prior to conception waiting period)
and you'll find that the monthly premium with
maternity is $230.
1.
How is the deductible per
person/? do I read it right $250.00
Yes,
there is a $250 annual deductible that applies to each
individual (no family deductible) and you may have
noticed a $500 Per admission deductible that applies
if you were to be admitted into a hospital that is out
of network; and finally there is a $500 Per Visit
Deductible (PVD) that only applies if you were to have
an emergency room visit where you were not admitted
nor had surgical services rendered. I view the
$500 PVD sort of as a penalty since it does not go
towards your annual out of pocket maximum (the maximum
you could pay in a year) of $2500; whereas, the PAD
(Per Admission Deductible) I noted above is included
in that $2500 maximum out of pocket amount.
2.
Is there coverage for
major medical?
Yes,
when you say major medical I am assuming you mean for
catastrophic coverage or inpatient and outpatient
services – and I would say yes to all of those
meanings. The only thing that is not covered is
a non-surgical service when performed in an outpatient
hospital facility services. Below you’ll see the
little snapshot indicating that only surgical services
are covered or services proximately related to
surgeries.
3.
What's the difference
between this and a HMO? What kind of plan is Miami
Dade Blue? If it is an HMO is also available as
a PPO and vice versa?
Yes,
that is correct this is a PPO. The difference is
that a Health Maintenance Organization (HMO) does not
have out of network benefits at all; that is to say
that if you have any services rendered out of the
specified service and network area you will be
responsible for all charges entirely. Whereas
with a (PPO Preferred Provider Organization) you can
choose to go out of network, however, you will find
with this plan along with all PPO plans that if you
were to go to a provider out of network the benefits
differ than if you were to have stayed within the
network. For instance, you’ll find that in that
snapshot above, you are subject to 40% coinsurance
instead of 10% coinsurance for any service out of
network. Well – at least, because even in these
examples you’ll find that you would also be
responsible to pay the balance of provider’s charges.
I
don’t mean to put you to sleep but let me provide one
quick example, although you can feel free to skip this
part if you’d like – I don’t mean to be redundant I
just think illustrations are useful.
So
below we have this one scenario:
Average provider’s charges
for this particular service in Miami Dade is $2854;
but the negotiated network rate that BCBSF has
with the provider for the procedure is $834.
You would first be subject to your annual
deductible of $250 and BCBSF would pay 90% of
the amount after you’ve paid the $250, $584
($834 - $250) which would mean that BCBSF would
ultimately pay $526 ($525.60 to be precise) and
you would be responsible for the remaining 10%
which is $58.40. Hence the member cost being
$308,the deductible of $250 and the 10% coinsurance
amount of $58.
4.
Does
Miami Dade Blue Cross Blue Shield have a pre-existing
clause?
Yes
there is a clause in the contract stipulating a 24
month pre-existing period; which would be waived if
you had proof of creditable coverage – that is
coverage that is similar to the new coverage and was
not terminated more than 62 days prior to the
effective date of your new policy.
Let me
know if you would like some additional details on
this, because in addition to the differences between
HMOs and PPOs I briefly mentioned above there are a
few other ones. With regards to the pre-existing
conditions PPOs can issue exclusionary riders and/or
rate modifications to your policy. So if you
have a pre-existing condition and state it on the
application and have creditable coverage they can
still issue your policy with an exclusionary rider in
which essentially states that they would not cover
that specific condition, body part, or what have you –
and it could be permanent or for 1 or 2 year periods
when you may be able to submit the necessary
documentation to have that rider reviewed and
hopefully removed from your contract. They may
also rate you up 25% - 150% on the standard premium
instead of or in addition to issuing the exclusionary
rider.
Point
of Service (POSs) are filed with the state as an HMO
and then have riders added onto their contracts to
make them a POS. IE Omitting the language in the
original HMO contract mandating a PCP be necessary and
referrals to specialists, etc. But since they
are not PPOs they cannot issue exclusionary riders, so
although they may rate you up they cannot exclude a
pre-existing condition.
Please
note that this is not directly related to pre-existing
condition clause that they also have – although it is
only 12 months usually, sometimes 24 months in which
they still have the right to not cover a pre-existing
condition should you not have had creditable coverage
within 62 days of your new plan’s effective date.
5.
The Miami Dade Blue Plan
is isn't good outside Miami-Dade County correct?
When
you say good, I am guessing you mean that you’re not
covered outside of Miami and the answer to that would
be no, you do have coverage outside of Miami.
But I would say Yes to it’s not good (you would have
more out of pocket costs) should you utilize “out of
network” benefits. In that example above with
the one procedure, if that were performed out of
network, BCBSF would only pay 60% coinsurance of the
contracted rate (in our example 60% of $834) and you
would be responsible for the remaining amount up to
the provider’s charges and not the contracted amount
as in network benefits mandate. So you would
ultimately be responsible to pay $2504; since BCBSF in
that example would only be paying $350.00.
But
that is out of network in FLORIDA, because
all non-Medicare BCBSF members are eligible for the
BlueCard Program which means you have national
coverage – benefits received at participating
providers of BCBS organizations are the same benefits
as your BCBSF (Blue Cross Blue Shield of Florida)
health plan.
